Methods of Influencing the Decisions of Psychiatric Patients: An Ethical Analysis J. S. Blumenthal-Barby, PhD, Laurence B. McCullough, PhD, Heather Krieger, BS, and John Coverdale, MD, MEd, FRANZCP Keywords: decision making, ethics, psychiatry INTRODUCTION Psychiatry has given considerable attention to the ethics of coercive methods, such as involuntary commitment and forced medications. This attention is warranted because patients with major mental disorders are vulnerable to impediments in decision making 1–4 and also to coercion and excessive pater- nalism. 5 What has not received adequate attention, however, is the ethics of subtle and routine forms of influence such as framing information, using rewards, and employing social norms. These forms of influence can powerfully shape patients’ thoughts, decisions, actions, and compliance. 6 As such, they should be carefully considered. In an effort to find a middle ground between excessive paternalism and protecting patients from imprudent decisions, reflective psychiatrists and men- tal health professionals will often struggle with when, how, and how much to influence patients’ decisions. In that con- text, our goals here are to develop a typology of influence on psychiatric patient’s decision making and to describe the ethi- cally relevant factors that should be considered. This frame- work should contribute to the ethical practice of psychiatry. METHODS We conducted a literature search on nonpharmacological in- fluences in psychiatry using Medline, Philosopher’s Index, PsycINFO, PubMed, and Scopus. A selection of the keywords used in the search included the following: psychiatr*, influ- ence, decision-making, ethics, framing, lying, persuasion, offers, coercion, and counsel*. We found 34 articles for in- clusion in our analysis. We also selectively identified routine examples of influence in clinical psychiatric settings in order to illustrate various elements of the framework. RESULTS: VARIETIES OF INFLUENCE We found one tripartite categorization of influences on patients’ decision making. This model, which was devel- oped purely theoretically, consisted of persuasive (through the merit of reason alone), coercive (though the use of cred- ible and severe threats of harm or force), and manipula- tive (everything in between) influences. 7 We did not find any extension of this typology or any typologies specifically developed for the practice of psychiatry. We identified seven distinct varieties of influence (Table 1): direct recommenda- tions, appeals to patients’ values and goals, appeals to norms, intentional framing of information or options, concrete in- centives, concrete threats, and deception. Direct Recommendation A direct recommendation occurs when all medically rea- sonable options are canvassed and a recommendation is made endorsing one or more specific options. For example, in the context of discussing all available options, a psychi- atrist may explicitly recommend that a sexually active female patient with bipolar disorder, and who uses contraception inconsistently, discontinue Depakote because of potential harms to the fetus in the event of a pregnancy. For another example, a psychiatrist may recommend to an inpatient to defer discharge in order to clarify the safety of a recently started medication. Direct recommendation can be power- fully influential; in one study, for example, some patients altered their preferred treatment choice when given a direct recommendation. 8 Appeal to Patients’ Values and Goals In discussing the available options with a patient, a psychi- atrist or other mental health professional may present rea- sons related to the patient’s long-standing values, goals, or beliefs. For example, knowing that a depressed woman very much cares for her children and that depression seriously impairs her ability to care for them to the point of possible involvement of Child Protective Services, a mental health professional could call attention to the positive effect that treatment would have on her continuing to parent her chil- dren in her own home. Likewise, a strongly religious person From the Center for Medical Ethics & Health Policy (Drs. Blumenthal-Barby and McCullough, and Ms. Krieger) and Department of Psychiatry (Dr. Coverdale), Baylor College of Medicine. Correspondence: Jennifer Blumenthal-Barby, PhD, Baylor College of Medicine–Center for Medical Ethics & Health Policy, One Baylor Plaza, MS 420, Houston, TX 77030. Email: Jennifer.Blumenthal-Barby@bcm.edu © 2013 President and Fellows of Harvard College DOI: 10.1097/HRP.0b013e3182a75d4f ETHICS Editor: Benjamin C. Silverman, MD Harvard Review of Psychiatry www.harvardreviewofpsychiatry.org 275 Copyright © 2013 President and Fellows of Harvard College. Unauthorized reproduction of this article is prohibited.